Counting miscellaneous items; counting during organ procurement; counting for sequential procedures; influenza vaccine; reprocessing

AORN Journal, Jan, 2006 by Bonnie Denholm

QUESTION: Recently, a patient had to return to surgery for removal of a retained petroleum jelly-impregnated gauze strip that had been used to prevent air leakage during a laparoscopic cholecystectomy. Currently in our OR, we document sharps, sponge, and instrument counts. We also count other items, but we do not document the miscellaneous items counted. 1 am now being asked to document everything we count on the intraoperative record. What miscellaneous items should be counted and documented by the perioperative nurse?

ANSWER: Documentation should include counts of sponges, sharps, instruments, and miscellaneous items. The "Recommended practices for sponge, sharp, and instrument counts" includes a glossary of these items? Although it is not an all-inclusive list, it is a good reference for miscellaneous items that should be counted. Examples given include

* electrosurgical scratch pads,

* ligaclip bars,

* trocar sealing caps,

* umbilical and hernia tapes,

* vascular inserts, and

* vessel loops.

Miscellaneous items that could be left in the wound inadvertently should be counted. Ideally, only items that contain a radiopaque marker should be introduced into the surgical site. Each health care facility should establish a policy to define the types of miscellaneous items that should be counted.

QUESTION: What is the recommended practice for performing counts during organ procurement procedures when the donor is deceased? Our facility has no policy on this, and we have conflicting opinions about whether an instrument count is necessary.

ANSWER: Sponge, sharps, and instrument counts should be performed during all organ procurement cases. Whether the donor is living or deceased, there should be consistency in practice and one standard of care provided to all patients.

Instrument counts are particularly important during deceased-donor organ procurement procedures because of the potential effect on subsequent counts during the recipient procedure. It is possible for an instrument from the donor procedure to be left in a procured organ unintentionally, causing a problem with inaccurate counts for the recipient procedure. Furthermore, sometimes instruments are included with or attached to the procured organ intentionally. The documentation from the organ procurement procedure plays a key role in reporting which instruments and how many may be added to subsequent counts for the recipient procedure. All sponges, sharps, and other miscellaneous items also should be counted.

Accurately accounting for sponges, sharps, and instruments during a surgical procedure is a proactive injury-prevention strategy. (1) Sharps or instruments that are not accounted for could injure personnel preparing a deceased donor for the mortuary or housekeeping personnel who are cleaning the room after the procedure. Injuries from sharps or instruments that are not accounted for also could expose personnel to potentially infectious material during environmental cleaning.

Perioperative RNs also have an ethical obligation to provide nursing care without discrimination. Every patient undergoing surgical or other invasive procedures deserves nursing care delivered in a manner that protects and preserves patient dignity and human rights. (2) Whether a procedure involves a deceased donor or a patient who dies unexpectedly, perioperative RNs should provide the same level of care to each patient.

AORN's "Recommended practices for sponge, sharp, and instrument counts" provides guidance for facilities establishing policies and procedures for count processes and quality control practices. Safety considerations include decreasing the risk of foreign body retention for patients on subsequent cases and decreasing the risk of injury or exposure to bloodborne pathogens for health care workers.

QUESTION: Recently, we cared for a patient who was undergoing a bilateral breast reduction followed by an exploratory laparotomy. Our facility policy requires an instrument count for laparotomies but not for breast reduction procedures. To reduce the time between procedures, the team in the room decided to open two instrument sets. They set up separate back tables for each procedure before the patient came into the room. Only the instruments to be used in the laparotomy were counted; the instruments for the breast reduction procedure were not counted. We had an incorrect count because something was taken off the counted set up and used in the uncounted procedure, which made the count for the counted procedure short one instrument. I believe the laparotomy instruments should not have been opened until the instruments from the breast reduction procedure were removed from the room. What is AORN's recommendation for instruments counts on multiple sequential procedures performed on the same patient?

ANSWER: An initial instrument count should be considered for all procedures where the incision potentially could be extended or there is an unusual set up. This is applicable for multiple sequential procedures performed on the same patient. An initial instrument count establishes a baseline for subsequent counts and decreases the risk of leaving an instrument in the patient if the scheduled procedure unexpectedly evolves into a more complex procedure. (1)